Internal Medicine Clerkship Tips

Oh yes, the internal medicine clerkship rotation.  Where you will go to learn that you don't know shit about some arcane thing about an organ system you brushed over in physio because you were gonna pass the class anyways and had to bust your butt on biochem just to pass.

But really the best way to impress is to show up early, and be eager.  Yes, eager.  That's how my resident told me I can get a good grade.  When I say eager though, don't be overbearing and annoying.  There's a fine line between the two.  You need to show interest, be happy to help, and bring a positive attitude to the team you're working with.  This, along with trying your best, will be enough to get you good feedback.

Don't worry about having to know certain things and details.  The knowledge you need to know will come from your shelf studying.  More important for your clinical grade is being able to write good notes, and being able to present well.  That is, presenting with confidence and conviction.  You'll get better at these things as time goes on.

Make sure to use some kind of MS3 survival guide to focus your efforts.  I used this one: http://som.uthscsa.edu/StudentAffairs/documents/MS3_Survival%20Guide.pdf


Here are some general topics you WILL encounter in your medicine rotation.

Know the majority of the chest pain differential.
- MI, esophageal rupture, pneumothorax, pericardial effusion, PE, aortic dissection.
- These 6 are potentially fatal chest pains you must rule out.

Know the shortness of breath differential.
- PNA, PE, pneumothorax, asthma, copd are obvious ones

Know the abdominal pain differential.
- This is more prevalent for surgery, and I'll address it in the surgery post.

And finally, know what to do in certain emergencies, such as hyperkalemia.
CBIGKDie
C - calcium gluconate - stabilizes cardiac membrane
B - bicarb or beta agonist
I - insulin
G - glucose to go with the insulin
K - Kayexalate
D - Dialysis

You'll need to know more than this stuff of course, but for some reason these stick with me over a year after the clerkship.

Internal Medicine Shelf Exam

I would love to tell you how to do well on this exam, but instead I'm going to tell you how I did, which is average, and how little I had to study.  My scaled score was a 75.

Now, I would have liked to do better, and I missed honors on this shelf by a few percent, but I'm here to set your expectations based on how I studied, so that you can do better.  Like I've been saying before, I'm a pretty average student, so most of you readers should get some benefit.  So here's what it takes to get an average grade.

First, start off your clinical year with internal medicine.  You won't know much of anything outside of step 1 material at this point.  Tell yourself how you're going to study really hard to do well on the shelf.  Start off strong by doing Pretest questions, and some Uworld questions.  Consider watching the Emma Holliday review video (link), and then don't actually watch it.  Consider watching the onlinemeded videos (link), and then don't actually watch it.

So far you're doing great, it's halfway through your clerkship, and you've done about 200/1200 of the medicine uworld questions, and about 1/2 of the pretest questions.  Most of your learning is being done at the hospital based on your patients and researching stuff on uptodate.

In other words, you need to kick it up a notch.  At this point you should get serious about studying.  Start breezing through uworld, and if you get something wrong, then learn that topic, and learn it well.  The books I used to learn stuff well was Case Files Internal Medicine, and Kaplan Step 2 CK.  I didn't even bother with Stepup, it's too dense for my liking.

Finally, you're in the last 10 days before your shelf exam.  You have about 300 uworld questions left, you stopped doing pretest, and you're only going to do the Emma Holliday review video because it's short.  Great! Now finish the questions, do 3 nbme practice exams, and watch the review video two times.  Take your test, and get an average score.

Next time:  How to honor your Pediatrics shelf because all it is is an internal medicine shelf.

Preclinicals and Realistic Step 1 Expectations

Alright, I never update this blog, and all you care about is what I titled this post.  So straight to the point.  My step score is in the 230s.  A good score, but still not good enough for anything real competitive like ortho, ent, derm, or uro.  Guess those are more than likely out.

You are most likely an average student like me.  Pretty good, but not stellar.  Good, this post is for you, because you also likely won't get 250s, even if you try all the things people with 250s do, you will end up having a score wall like I did.

To do well on step the number one thing is to do well in your preclinical classes.  I got a few questions right only because I remembered random shit from first and second year.  My friends who crushed step were rockstars in years 1 and 2.  I'm serious, try very hard to do your best.

My second year progressed like this leading into step:

• First half of year, don't even think about step.
• I used PATHOMA for my pathology course.  This is the NUMBER ONE way to study for step indirectly.
• I also used sketchy micro,  and sketchy pharm.  NUMBER TWO way to study for step indirectly.
• Second half started uworld.  I got through half of it before dedicated.
• Also tried starting first aid, but it was HELLA boring. (You can use a one year old first aid by the way, though I wouldn't go further back than that.)
• Just before dedicated.  You will have finals for your second year courses, and so you WILL KNOW pathoma and sketchymicro and sketchypharm very well right before dedicated.
• Dedicated (5 weeks):
• I took an nbme to see where I stood.  (Don't get discouraged if you do poorly.  It is a challenge to your psyche to kick ass when you get a shit practice score.)
• I focused mostly on uworld questions, and I tried to study first aid at ~2chapters/day.
• I did ~120 questions/day, with one block focused on material I read in First Aid that day, rest random.
• First aid soon fell to the wayside about 2 weeks in, and it became a reference instead.  
• Each week on the weekday I was set to have my test, I would take an nbme.  I did this every week leading up to the test, improving a little bit each time.  My step score was within 5 points of my last, and best test.  (Do newer nbmes last since they'll be most like the real thing.)

There you have it.  If you're an average/above average student, and try as hard as you can, you will get at least an average/above average score.  But to really get a high score you have to do as well as you possibly can in years 1 and 2.  Comment if you have questions on anything.

First Year Update 1:

It's currently Thanksgiving break, and I actually have some free time to make a Blogger post!

So, I'll just start from the beginning of the year.  In August, we basically had very little studying to do (relative to now that is).  There were also a bunch of social events with free food before classes started.  Note, FREE FOOD.  Needless to say you should attend these.  Not only is there free food, but they're one of the few times that you can really have a shot at meeting new people before everyone's core group of med school friends start to form.

Now, on to the school work!  At my school they started us off with Biochem, Genetics, Microanatomy, and some not so science based physician skills classes.  As the weeks went by though they added Gross Anatomy, Physiology, Nutrition, and Immunology to the mix.

When you first start med school you'll likely do one of two things: study too much, or study too little.  And you'll most likely not know what you need to know.  This is a skill you will learn as you go through med school.  

To be clear, the hardest part of med school is NOT being able to understand the material; it's getting through the large amounts of material, and picking out the high yield material for exams.

On our first set of exams, we were only tested on Biochem, Genetics, and Microanatomy.  The averages were in the 80s, but there were quite a few people that didn't pass (below 70% score).  As for myself, I studied way too much.  I did well, but not much better than the average.  Since then we've had a ton of exams and material.   

Also, I've learned some more effective study habits these past few months.  Such as don't study too much, study more effectively, and make time where you don't study at all.  If you study non-stop for hours without any breaks, the material won't stick.  And make sure you get enough sleep.  The people that study straight through depriving themselves of breaks, sleep, and other hobbies simply don't appear as confident coming out of exams, and personally I didn't do much better studying that way.

With that stuff said I've found I'm an average/sligthly above average student at my med school.  I'm not particularly annoyed by it because I'd be happy with a midrange competitive specialty like internal medicine, and I'm not sure I'm capable of gunning for 100s on every exam.  I don't really feel like studying that hard at times anyways.

Instead I'm going to continue to enjoy my time by participating in extracurriculars, spending time with friends and family, and keeping up with my hobbies.  Or in other words, I'm enjoying living a healthy life and not making studying my life.  If you do this though make sure you pass everything.  School is still my top priority.  Good luck!

HPSP: Health Professions Scholarship Program (Army, Navy, Air Force scholarships)

Figure 1: 'Nuff said.

Intro

Hpsp is the health professions scholarship program from the military. You can apply for one through the army, navy or Air Force, or all of them at once, and pick from whichever branch awards you one. It pays for all tuition, fees, books, and some equipment needed while in med school. They will NOT pay for a computer though.  You also get a $20,000 signing bonus, and a $2,100 per month stipend as a student.  The bonus gets paid out in installments three installments, starting on your first month of medical school.

Years owed to army

You owe the army one year for each year of school paid, or one year for each year of residency. Whichever is greater. Then you owe a few years of inactive ready reserve, where they only call you up for work if absolutely needed. This all has to total eight years. So if you do a 5 year Ortho residency, you owe 5 years active duty, and 3 years inactive duty. 

Why I signed up/ Residency stuff

I signed up for it because med school is expensive, I want to serve America, and I don't want to deal with the cons of the civilian healthcare system (ex: you don't need to buy malpractice insurance as a military physician). With that said, it has it's cons. If they critically need more of some type of doctors, it is ultimately their decision which residency I can do. If they need you to go somewhere foreign, like Germany, Japan, or Korea, you need to go. Also, during your inactive ready reserve period, they can call you up if there is a major conflict with another country.  This is unlikely because it apparently didn't happen with the last two wars.

I also did it for the chance to travel, and do something different from the pack. I'm honestly really excited to learn more about, and become a part of the military.  Furthermore I really do love America, and I want to support the country in this way.

I want to do something with surgery or procedures. I'm thinking Ortho or EM. On that note, the military residency match is in the early Fall. So you'll know where you're going before everyone else's match day. You CAN do a civilian residency in something if they need more of it. It's kind of a gamble though, because if you don't match they have you do primary care work or something for like 3 years. I haven't really looked to to that too much though. 

It's really up to you if you are into it.  People on the internet say to do it only if you are serious about serving the USA.  I am serious and want to, but at the same time, I do not want to have $350,000 (65 for my undergrad + 4*70 for med)  of student debt at ~7% compounding interest.  Doctors don't make as much money as they used to, and tuition is only going up, while pay for doctors is going down.

Pay in the Army

The Personal Statement

Figure 1: How I feel when I read an old essay.

Before I wrote my personal statement I read the book Essays That Will Get You into Medical School (link is to the newest edition).  We all know how to write an essay, but the reason I decided to read this is to find out what successful applicants wrote.  When I read some of those essays, all I could think was ho.... ly... shit, these are some really really good essays.  And they were AMAZING, not all, but most.  You don't need to be that amazing though.  The book will give you some insight into how to take your essay from typical, to pretty good.  As long as the rest of your application is strong that's about as much as you need.

Now, you should not let your essay be typical.  Here's what a typical med school app essay focuses on: 

• Wanted to do medicine since I was a child.
• My grandparent died and I found out medicine was my true calling.
• My dad/mom is a doctor and I don't want to do anything else.

These are not BAD reasons to go into medicine, but they are typical, and will make for an uninteresting essay.  The admissions committee is skimming reading thousands of these, and I bet most essays sound the same.  Hopefully you've fostered other hobbies and interests, or you have had meaningful experiences outside of medicine that you can also talk about.   For to help pay for my college education, I worked every semester.  In my essay I talked about my work experiences and how I have been shaped by them.

With that said, the central focus of your essay has to be why medicine.  You need to show that you're not a premed robot, and illustrate that you're an interesting person, but you absolutely have to answer why medicine.  If your essay does not answer that question, it's pointless.

As a final note, your premed adviser will probably want to read your essay and help you with it.  I recommend you do this, but don't solely rely on them.  Talk to them to make sure the content and aim is correct, then seek out English writing professors for grammar and structure details.  

Good luck!

References: Figure 1

Pharmaceutical ads

So I wrote this short essay for a class recently.  It's on the effectiveness of a pharmaceutical ad for the antidepressant Pristiq:

       Pharmaceutical ads have been around as long as I can remember, which is the 90’s.  The reason is that in the 1980’s the FDA allowed drug manufacturers to begin advertising directly to consumers.  Prior to this, they were only allowed to advertise to healthcare professionals.  The drug ads we see on TV are called Direct-To-Consumer Pharmaceutical Advertising (DTCPA).  You should be familiar with these ads, as drug companies spend billions every year to advertise.  In fact, a study from 2004 showed that pharmaceutical companies spend twice as much on advertising as they do on research and development. [1]

        Since drug companies spend so much on advertising, these commercials are surely effective.  Two of the most important things in these commercials is the imagery and actors used.  We know that the information is obviously important, but more on that later.

The ad I would like to discuss (because it came up first on Google) is a commercial for Pristiq.  Pristiq is the brand name for the molecule called O-desmethylvenlafaxine.  It is an “antidepressant of the serotonin-norepinephrine reuptake inhibitor class developed and marketed by Wyeth (now part of Pfizer).” [2]

In the commercial, a lady is describing how depression affects her life, vaguely and with buzzwords of course.  She says that she has to “wind herself up” just to get going.  Meanwhile, the music is in the minor scale, and also depressing.  The lady looks and sounds unhappy, and so does the music.  You feel unhappy too now!  You can relate to the lady in the commercial, and are being affected as the advertisers intended.

Then, you are shown Pristiq.  Glorious glorious Pristiq!  It is even “proven to treat depression”. [3]  At the same time the scale the music is played in changes to major, more instruments are added, a nonspecific science looking clip showing neurotransmitter uptake is fed to your eyes.  And of course, our actress is now smiling.  She is happy, and you can be too!

The rest of the imagery in the commercial makes little sense to me.  The same lady is shown trying to sell some kind of vase to a couple?  Meanwhile we get to learn about all of the horrible, yes horrible side effects.  Such as the higher risk of suicide...  Anyway, the goal of the commercial is to get you to request this drug from your doctor if you experience symptoms of depression.  I find that the commercial is quite effective as it affects my moods with its imagery and audio cues.  The side effects dialogue, while important, is boring, and I obviously do not listen to it too intently.  Either way, if I was depressed, I would definitely be asking my doctor about Pristiq.

References

[1]  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174966/

[2]  https://en.wikipedia.org/wiki/Pristiq

[3]  https://www.youtube.com/watch?v=uVNZ8ZBP5gY